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A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
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A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurological disorders should the nurse suspect?
- A. Embolic stroke
- B. Thrombotic stroke
- C. Transient ischemic attack (TIA)
- D. Hemorrhagic stroke
Correct Answer: D
Rationale: The sudden severe headache followed by seizure and unresponsiveness with elevated BP suggests hemorrhagic stroke.
A nurse is preparing to administer intermittent lipid emulsion and notes a layer of fat floating in the IV solution bag. Which action should the nurse take?
- A. Shake the bag to mix the fat.
- B. Administer the bag of solution.
- C. Return the bag to the pharmacy.
- D. Turn the bag upside down one time.
Correct Answer: C
Rationale: Fat separation indicates instability; solution should be returned to pharmacy as it could cause fat embolism.
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.
A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?
- A. Weight gain
- B. Use of alcohol
- C. Abdominal pain relieved with food or antacids
- D. Exposure to occupational chemicals
Correct Answer: B
Rationale: The use of alcohol is the most common cause of chronic pancreatitis, accounting for about 70% of cases.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
- A. Evaluate for asterixis
- B. Palpate for peripheral edema
- C. Evaluate for decreased level of consciousness
- D. Inspect for petechiae
Correct Answer: B
Rationale: Peripheral edema occurs with hypoalbuminemia due to decreased oncotic pressure causing fluid leakage into tissues.